Nursing Field Notes / Nursing Core · Fundamentals of Nursing
Pain Management 🩹
The foundations — what pain is, the four types, and how the nurse builds the plan
NG-008Nursing CoreFoundational overview
Pain is very personal — both physical & emotional. Everyone experiences pain; nobody experiences it the same way. What feels unbearable to one client may barely register for another. This page is the foundation: the concept, the four types, and the plan.
🗣️ Pain is what the client SAYS it isOccurring whenever they say it does. Self-report is the gold standard.
📉 Only ~5% exaggerateSo acknowledge the pain. Doubt is not an assessment finding.
4️⃣ Acute · Chronic · Phantom · ReferredPhantom pain is REAL pain. Referred pain shows up somewhere else.
🤝 REALISTIC goals, client involved“Zero pain” is usually not the goal — function is.
🧠
WHAT PAIN IS
STEP 1 · THE CONCEPT
A signal that travels a real anatomical road — and a personal experience shaped by everything the client brings with them.
🧠 The pain pathway — skin → cord → brain (and the brake on the way back)
Pain has to be perceived by the brain to exist. That is why distraction, relaxation and cognitive strategies genuinely reduce pain — they act on the last step of the road, not on the imagination.
🧠 “Skin sends it, cord relays it, brain decides it.” Every non-drug technique you will ever teach works by nudging one of those three stations — mostly the last one.
⭐ Five things that change how pain is perceived
Ethnic & cultural variables — expression of pain is learned, not universal.
Developmental stage — a toddler, a teenager and an 85-year-old report pain very differently.
Environment & support people — alone at 3 a.m. hurts more than surrounded by family.
Previous pain experience — a bad past experience amplifies the next one.
Meaning of the pain — “if the chemo hurts me, it means it's working” can make identical pain tolerable.
🧠 “C-D-E-P-M” — Culture · Development · Environment · Previous pain · Meaning. Five dials on the same volume knob.
🚨 The belief rule — and the number behind it
Only about 5% of people who report pain are found to be exaggerating.
So the nursing response is to acknowledge the pain — not to audit it. Suspicion is not a nursing intervention, and it will cost you the point on the exam every time.
Never withhold ordered analgesia because you personally doubt the report, because the client was laughing, or because the vital signs look fine.
🧠 “95 out of 100 are telling you the truth.” Treat the 95. The 5 will be sorted out by the whole team, not by you refusing a dose.
😬 Acute vs chronic — and the trap that catches everyone
🧠 “Acute shouts, chronic whispers.” Acute pain fires the sympathetic nervous system; chronic pain has been there so long the body stopped reacting. Believe the whisper.
🔎
TYPES & SOURCES · THEN ASSESS
STEP 2 · NAME IT
Four types on the source sheet, plus the two mechanisms that decide which drug will actually work.
📚 The four types of pain — one line each
Type
What it means
Example
⚡ Acute
Sudden, severe, short-term pain. Has an obvious cause and an expected end.
A new bump or bruise; a fracture; post-op day 1
🕰️ Chronic
Long-term pain — “recurring, over an extended time.” Often outlives the injury.
Back pain (long-term); osteoarthritis
👻 Phantom
Pain that feels like it is coming from a body part that is no longer there. REAL pain — never dismiss it.
After an amputation
↔️ Referred
Pain felt in one part of the body caused by injury in another part.
Chest pain from an MI triggering jaw pain
🧠 “A-C-P-R: A Cranky Patient Reports.” Acute · Chronic · Phantom · Referred. And the two that get dismissed by careless nurses — Phantom and Referred — are the two most likely to be tested.
↔️ Referred pain — organs send their pain somewhere else
Visceral organs and skin share spinal segments, so the brain misreads the address. An inferior wall MI can present as jaw, neck, shoulder or epigastric pain with no chest pain at all — classically in women, older adults and people with diabetes.
🧠 “The organ complains, the skin gets blamed.” Jaw = heart. Right scapula = gallbladder. Left shoulder = spleen. Flank to groin = kidney stone. Umbilicus drifting to the RLQ = appendix.
👻 Phantom pain is REAL pain — and it has a real mechanism
Never tell a client the limb is gone so the pain cannot be real. Acknowledge it, medicate it, and report it — neuropathic pain often responds poorly to opioids alone.
🧠 “The map outlives the limb.” The leg is gone; the brain's picture of the leg is not.
🧪 Two mechanisms that decide which drug works
Nociceptive — real tissue damage. Somatic (bone, muscle, skin — sharp, well localized) or visceral (organs — deep, cramping, poorly localized, often referred). Responds well to NSAIDs, acetaminophen, opioids.
Neuropathic — nerve itself is damaged. Burning, shooting, electric, tingling, numb. Diabetic neuropathy, post-herpetic neuralgia, phantom limb, sciatica. Often responds better to adjuvants (certain anticonvulsants and antidepressants) than to opioids alone.
🧠 “Burning & buzzing = nerves.” If the client describes electricity, opioids alone will disappoint — that is your cue that co-therapy is needed.
📏 Rating it — the short version
📎 The full assessment page is NG-086 Pain Management (detailed) — PQRST, the numeric (0–10) scale for clients who can self-report, Wong-Baker FACES for young children and others with limited verbal ability, FLACC for infants and non-verbal clients, and the WHO analgesic ladder. Use this page for the concept; use NG-086 for the tools.
🧠 Always reassess. Oral analgesic ≈ 60 min, IV ≈ 15–30 min — check your facility's standard, then chart the new number.
💊
PAIN MANAGEMENT STRATEGIES
STEP 3 · THE PLAN
Formulate a plan, set a realistic goal, keep the client in the driver's seat — then layer drug and non-drug together.
✅ Formulate a plan — five moves, in order
1
🤝 Acknowledge the pain. Believe it first; everything else fails without this.
↓
2
🎯 Educate the client to set a REALISTIC pain goal. Often “a 3 so I can walk and sleep,” not a zero.
↓
3
🧍 Keep the client involved in the strategies used to manage the pain.
↓
4
😌 Reduce anxiety about the pain. Fear amplifies pain; explanation and presence lower it.
↓
5
🧩 Combine pharmacologic + non-pharmacologic — multimodal beats either one alone.
🧠 “A functional goal, not a number goal.” Ask “what do you want to be able to do?” — cough, walk to the bathroom, sleep four hours. That is a goal you can both evaluate.
💊 Pharmacologic treatment — the three tiers
Non-opioid — NSAIDs and acetaminophen. First line for mild pain, and kept on board even when opioids are added (they are opioid-sparing).
Opioids — for moderate to severe pain. Watch sedation and respiratory rate before the pain score.
Co-therapy / adjuvants — drugs whose main job is something else but that help specific pain: certain anticonvulsants and antidepressants for neuropathic pain, muscle relaxants for spasm, corticosteroids for inflammatory or bone pain, local anesthetics.
📎 Drug detail lives in the Pharmacology batch: NG-257 Opioids · NG-256 NSAIDs · NG-232 Acetaminophen · NG-259 PCA pump vs fentanyl. Doses, antidotes and toxic ranges are there — not here.
🧠 “Non-opioid stays on the bottom of the stack.” Adding an opioid does not mean stopping the acetaminophen — combining them lets you use less opioid.
⚠️ Opioid safety — the non-negotiables
Sedation comes before respiratory depression. A client who is hard to rouse is the warning sign — assess the level of sedation every time.
Have naloxone and a means of ventilation available per policy.
Constipation never develops tolerance — start a bowel plan on day one.
Fall risk, orthostatic hypotension, urinary retention, nausea, pruritus.
Never crush or split an extended-release opioid tablet.
Never let a family member press the PCA button for the client — PCA by proxy is how PCA kills people.
🧠 “Sedation is the smoke; respiratory depression is the fire.” You act on the smoke.
🧘 Non-pharmacologic treatment — free, safe, and testable
🌬️Breathingtechniques
📺DistractionTV, reading, games
🔥Heatspasm, stiffness, chronic
🧊Coldacute injury, swelling
😴Restand sleep hygiene
🧘Meditationguided imagery
💆Massage& repositioning
🎵Music& company
🛏️Positioningsplinting, pillows
⚠️ Heat vs cold rules: check skin before and after, a barrier between the pack and the skin, 15–20 minutes at a time, and extra caution with impaired sensation, neuropathy, poor circulation and confused clients.
🧠 Non-drug measures are almost always a correct answer — but they are an addition, not a substitute. “Reposition and offer distraction” never replaces “give the ordered analgesic” for severe pain.
🚨 Special populations — where pain gets missed
Non-verbal / advanced dementia — use a behavioral tool. Grimacing, guarding, restlessness, moaning, refusing care and new agitation are pain until proven otherwise.
Infants & young children — behavioral scoring; parents' report matters.
Older adults — under-report because they expect pain, fear addiction, or fear being a bother. Ask specifically about function.
Clients with substance use disorder — often need more, not less. Tolerance is not addiction; treat the pain and involve the team.
🧠 “New confusion in an older adult = look for pain (and infection).” Delirium is a pain presentation more often than students expect.
📊 Evaluate — did the plan work?
Reassess at the drug's expected peak and chart the number.
Ask about function: did they cough, walk, sleep, eat?
Check side effects — sedation, RR, bowels, nausea.
If the goal was not met, go back to assessment: is the pain a new problem? wrong mechanism? wrong route? dose interval too long?
New, sudden, severe or different pain is a red flag — report it rather than medicate it.
🧠 “Different pain = report, don't just dose.” A post-op client whose pain suddenly changes character may be bleeding, ischemic, or compartment-syndromic.
⚡
QUICK RECALL
SAY IT OUT LOUD
🗣️ Believe itPain is what the client says it is. ~5% exaggerate.
4️⃣ A·C·P·RAcute · Chronic · Phantom · Referred.
😴 Sedation firstAssess sedation & RR before the pain score on opioids.
Q1: A client rates pain 8/10 but is smiling and talking on the phone with normal vitals. What do you do?
Treat the 8. Pain is what the client says it is; behavior and vital signs do not disprove it, especially in chronic pain where the autonomic response has adapted.
Q2: Define phantom pain and say whether it is real.
Pain that feels like it is coming from a body part that is no longer there — classically after an amputation. It is REAL pain and must be assessed and treated.
Q3: A client with an MI reports jaw pain. What is this called?
Referred pain — pain felt in one part of the body caused by injury in another. Heart → jaw, neck, left arm, shoulder or epigastrium.
Q4: The client's pain goal is “zero.” How do you respond?
Educate toward a realistic, functional goal — a level that lets them cough, walk, sleep and participate in care — and keep them involved in choosing the strategies.
Q5: Which pain description makes you think “this may not respond to an opioid alone”?
Burning, shooting, electric, tingling — neuropathic pain. Adjuvant co-therapy is usually needed alongside.
Q6: Name six non-pharmacologic strategies from the source list.
Breathing techniques, distraction (TV, reading, games), heat or cold application, rest, meditation, and massage.